Temporal Artery Biopsy
Suspected giant cell arteritis
Same
[Right / Left] temporal artery biopsy
[***, MD/DO]
[Resident/PA name]
Local: [X] mL [1% lidocaine / 1% lidocaine with epinephrine]
The patient is a [age]-year-old [male / female] with suspected giant cell arteritis, presenting with [new headache / jaw claudication / scalp tenderness / visual symptoms / polymyalgia rheumatica symptoms] and [an elevated ESR and CRP / ***]. [Corticosteroids were started on [date].] The risks, including bleeding, infection, scarring, injury to the frontal branch of the facial nerve, hair loss along the incision, and a false-negative result, as well as the benefits and alternatives, were discussed, and informed consent was obtained.
The [right / left] superficial temporal artery was [normal in appearance / thickened / nodular / tender / pulseless]. A [X]-cm segment was excised.
The patient was placed supine with the head turned to the [left / right]. The course of the superficial temporal artery was identified by [palpation / Doppler / ultrasound] and marked. [The hair along the planned incision was clipped.] The area was prepped and draped, and a time-out was completed. Local anesthetic was infiltrated along the incision, superficial to the artery.
A [3]-cm incision was made over the [main trunk / parietal branch] of the artery above and anterior to the ear. Dissection was carried through the subcutaneous tissue to the temporoparietal fascia, and the artery was identified and dissected free over a [3]-cm length. Side branches were controlled with [4-0 silk ties / bipolar cautery] away from the specimen. The artery was ligated proximally and distally with [4-0 silk / 3-0 Vicryl], and a [X]-cm segment was excised without crushing or cauterizing the specimen. The specimen was placed in formalin and sent for permanent section.
Hemostasis was confirmed. The subcutaneous tissue was closed with interrupted [4-0 Vicryl] sutures, and the skin was closed with [interrupted 5-0 nylon / a running 5-0 Monocryl subcuticular] suture. [Bacitracin and a dry dressing / Skin adhesive] [was / were] applied.
None
[Right / Left] temporal artery segment, [X] cm, for permanent section
Minimal
None
The patient tolerated the procedure well and was discharged home in stable condition. [Corticosteroids were continued.] Pathology results will be reviewed with the [rheumatology / referring] team.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Suspected giant cell arteritis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Right / Left] temporal artery biopsy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: Local, *** mL [1% lidocaine / 1% lidocaine with epinephrine]
INDICATIONS: .PTAGE-year-old .PTSEX with suspected giant cell arteritis, presenting with *** and ***. [Corticosteroids started ***.] Risks including bleeding, infection, scarring, facial nerve frontal branch injury, hair loss along the incision, and false-negative result, along with benefits and alternatives, were discussed. Informed consent obtained.
FINDINGS: [Right / Left] superficial temporal artery ***. *** cm segment excised.
DESCRIPTION OF PROCEDURE:
Supine, head turned. Artery course marked by [palpation / Doppler / ultrasound]. Prepped and draped. Time-out completed. Local infiltrated. *** cm incision over the [main trunk / parietal branch] above and anterior to the ear. Dissected to the temporoparietal fascia, artery freed over *** cm. Branches controlled away from the specimen. Ligated proximally and distally, *** cm segment excised without crush or cautery, sent in formalin. Hemostasis confirmed. Subcutaneous tissue closed with 4-0 Vicryl, skin closed with ***. Dressing applied.
COMPLICATIONS: None
SPECIMENS: [Right / Left] temporal artery, *** cm, permanent section
ESTIMATED BLOOD LOSS: Minimal
DRAINS: None
DISPOSITION: Tolerated well, discharged home. Pathology to be reviewed with *** team.
Signed: .ME, .MYDEGREE
.TODAYVariants
Contralateral Biopsy
Because [the first biopsy was negative and clinical suspicion remained high / symptoms were not localized to one side], a [left / right] temporal artery biopsy was performed through a separate incision in the same manner. A [X]-cm segment was excised without crushing or cauterizing the specimen and sent separately for permanent section.
Charting Tips
- Record the specimen length. ACR guidance favors a segment longer than 1 cm, because giant cell arteritis is segmental and a short specimen can miss skip lesions. The artery shrinks in formalin, so excise generously.
- Document the corticosteroid start date. ACR guidance favors biopsy within 2 weeks of starting steroids, and treatment should not be delayed for the biopsy.
- A unilateral biopsy is the usual first step. Contralateral biopsy is reserved for a negative first side with continued suspicion or symptoms that do not localize to one side.
- Biopsy the main trunk or parietal branch above and anterior to the ear. The frontal branch of the facial nerve runs with the frontal branch of the artery across the zygomatic arch, so document forehead movement after the procedure when dissection was anterior.
- Do not crush, clamp, or cauterize the specimen. Handling artifact can obscure the diagnosis.
Documentation & Reimbursement Considerations
- Primary service: Report Temporal Artery Biopsy as the primary service when it is the definitive operation performed.
- Temporal artery biopsy carries 2.97 wRVU and a 10-day global period. A contralateral biopsy on the same day is reported for each side with laterality modifiers.
- A contralateral biopsy at a later date after a negative first side is a separate procedure. If it falls within the first side's global period, append the modifier for a staged or related procedure and document the negative first biopsy that prompted it.
- A same-day office visit is billable only when a separately identifiable evaluation is documented beyond the decision to perform the biopsy.